Proverbs 12:25
An anxious heart weighs
 Hypothalamus controls body’s temperature
 Temperature is the balance between heat production and
heat losses
 Factors that affect temperature are BMR, Age, thyroxine
output, Hormones, time, stress
 Alteration in temperature includes pyrexia (38.1C above),
hyperpyrexia (41C) and hypothermia (35 C below)
 Tympanic temperature reading best reflect core
temperature
 Pulse is control by the Autonomic Nervous System
 Factors that affect pulse rate are age, gender, position,
medication, stress
 Apical pulse should be assess on a lying position
 Carotid pulse is assessed for cardiac arrest for adult and
brachial pulse for infant and child.
 Defibrillation kills the heart temporarily
 Respiration is controlled by Medulla oblongata and Pons
 Factors that affect respiration are age, environment,
altitude, stress, medication
 Blood pressure is determined by blood volume, elasticity of
the blood vessels, hematocrit level and peripheral
resistance
 Orthostatic Blood pressure measurement is used to monitor
the drop of blood pressure.
 Physical assessment is used to confirm, validate and refuse a
data
 Cephalocaudal approach is used when doing physical
assessment
 The four modes of physical assessment are Inspection,
palpation, percussion and auscultation
 Consent must be obtained for physical assessment
 Privacy should be observed in conducting physical
assessment
 Thermotherapy increased superficial temperature and local
metabolic rate,
 Heat therapy is contraindicated for acute muscle injury,
impaired circulation, sensory impairment, bruises and open
wound
 In most hospital, the water temperature is controlled at a
temperature not to exceed 43.3 C to prevent injury
 Petroleum jelly may be used to prevent tissue damage when
hot packs are applied
 Monitor Vital sign frequently when systemic cold is applied
 When using hypothermia blanket, use towel to wrap hands
and feet to protect skin from injury
 Observe skin for purplish color, and check client for numb
feeling after cold application are removed
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/7350740
a man down…
 Do not allow the client to lie on a “constant heat source”
such as heating pad or aquathermic pad
 Do not apply heat to an edematous area until the reason for
edema has been determined
 Gel packs provide more aggressive cooling than ice bags, so
deserve grater caution
 During cold therapy, erythema will occur
 The four stages of cold progression are cold, stinging,
burning, numbness
 Discontinue cold therapy upon numbness
 Never apply a fully cooled cold packs directly to the skin
 Bony areas usually requires half the treatment time as fatty
areas
 Do not apply an instant chemical pack to the face and never
use pins to secure pack
 Elderly clients are more susceptible to injury from heat and
cold therapy as a result of physiologic changes or medical
conditions
 Vital signs and frequent assessment may need to be carried
out during heat and cold therapy as vasodilation from heat
or vasoconstriction from cold can cause changes in cardiac
function and blood pressure
 Pressure sore is caused by three basic factors: pressure,
friction, shearing force
 Factors that might be at risk in developing a pressure sore
are: malnutrition, increased temperature, decreased
protein intake, decreased sensation, decreased mental
capacity, immobility
 Pressure ulcer are graded from stage 1 to 4
 The three major phases of wound healing are inflammation,
proliferation and maturation
 The RYB (red, yellow, black) classifies open wounds that are
healing by secondary or delayed primary intention in both
acute and chronic wound
 The three types of wound healing are primary, secondary
and tertiary intention
 The goals of wound healing includes: remove necrotic
tissue, prevent infection, absorb drainage, maintain a moist
environment, protect wound from further injury
 Ensure that skin is kept clean and prevent it from getting
too dry
 Provide a balanced diet high in protein, vitamins and
mineral for tissue repair
 Ensure a fluid intake of 2,000 mL/day for adequate
hydration
 Do not elevate head of the bed more than 30 degrees
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 Reposition a bedridden client at least every 2 hours and a
chair bound client every hour
 Common fecal elimination problem includes constipation,
diarrhea, incontinence, flatulence
 Lack of exercise, irregular defecation habits, bland diet and
overuse of laxative are all thought to contribute to
constipation
 Sufficient fluid and fiber intake are required to keep feces
soft
 An adverse effect of constipation is straining during
defecation
 An adverse effect of prolonged diarrhea is fluid and
electrolyte imbalances
 When inspecting the client stool, the nurse must observe its
color, consistency, shape, amount, odor, and the
constituents
 Digital removal of an impaction should be carried out gently
 Enema is used to relieve constipation, fecal impaction,
flatulence and is also used for evacuation and in lowering
body temperature
 Proper positioning must be observed in doing enema. Left
lateral position for adults and dorsal recumbent position for
child and infants
 Urinary elimination depends on normal functioning of the
urinary, cardiovascular and nervous system
 Alteration in urine production and elimination includes
polyuria, oliguria, anuria, frequency, nocturia, urgency,
enuresis, hematuria, incontinence and retention
 Incontinence can be physically and emotionally distressing
to client
 Clients with urinary retention is at risk for tract infection
 The most common cause of urinary tract infection is
invasive procedure
 Goals for client with problems with urinary elimination
problems includes maintaining or restoring normal
elimination patterns and preventing skin breakdown
 Urinary catheterization is frequently required for clients
with urinary retention but is only performed when all other
measures to facilitate voiding fails
 Gradual decompression should be done in doing straight
catheterization
 Fr 16 – 18 is used from male client and Fr 12 – 14 is used for
female client for catheterization
 For retention catheter, inflate the balloon with 5 ml of
sterile NSS
 For client with retention catheter, acidifying urine is a must.
Food such as meat, fish, eggs and cereals
 Normal pH of urine is 6 or a range of 4.6 – 8
 Clean voided specimen is used for routine urinalysis
 Midstream urine specimen is used for urine culture
 Timed urine specimen collection is used to assess the ability
of the kidney to concentrate and dilute urine; determine
level of specific constituents; determine disorders of glucose
metabolism
 If the client or staff forgets and discard the client’s urine
during times collection, the procedure must be restarted
from the beginning
 To collect a stool specimen for infant, the stool is scraped
from the diaper
DR. CARL E. BALITA REVIEW CENTER TEL. NO. 735-4098/7350740
 For occult blood examination, the client should be
instructed to avoid dark-colored food, red meat, iron and
hemoglobin rich food for 48 – 74 hours
 Avoid collecting specimen during menstrual period
 Sputum specimen is best collected early morning to help the
client expectorate all the secretions that has been
accumulated at night
 Method of sputum collection includes deep breathing and
coughing exercise, suctioning and chest physiotherapy
 Blood test are the most commonly used diagnostic test and
can provide valuable information about the hematologic
system and other body system
 Walker promotes more stability compare to cane and
crutches
 Crutches observes different gaits such as: 4 point gait, 3
point gait and 2 point gait, plus swing to and swing through
 Cane should always be places on the stronger side of the
body
 Client should always be free from restraint
 Reason for placing the client on a restraint includes:
disruptive behavior, procedure and transfer
 Never anchor the restraint on the side rail
 Free movement should be provided when placing the client
on a restraint
 Two types of visualization are direct and indirect. Direct
methods make use of gadget or instrument to visualize a
body area/organ. Indirect methods make use of dye,
electrical impulses
 KUB X-ray (kidney, ureters, bladders) are painless
 For voiding cystourethrogram films are taken before, during
and after voiding
 Retrograde pyelogram (RPG) outlines the pelvis and ureters.
Epinephrine at the bedside should be prepared
 A pink tinged urine is normal after cystoscopy because of
the irritation of the mucus membrane
 Distending bladder for KUB ultrasound is done for better
imaging
 A 24 hours bed rest after renal biopsy is encouraged to
prevent bleeding
 Blood Transfusion is used to improve the oxygen carrying
capacity of the blood and restore the blood volume
 0.9% NaCl is the only fluid solution allowed for blood
transfusion
 Label the blood and warm the blood at a room temperature
 Use needle gauge 18 or 19 for BT to allow easy flow of the
blood
 Do not mix medication with blood transfusion
 Stop the transfusion immediately for any complication that
might occur during blood transfusion
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